OK, did a search and didn't find this exact question answered, maybe someone can point me in the right direction. I think I know how this should work, but some of these rules are tricky.
U65 just got her disability awarded and has been enrolled in Medicare A&B. She is still within the window to decline B. She is currently covered under her husband's active employment GHP. His employer is a large-group (over 100 employees), so from what I can tell GHP would be primary if she keeps both.
She wanted to know how Medicare would pay if she stayed on the B rather than declining it. Assume that the GHP coordinates benefits.
What I am not 100% clear on is outpatient and doctors balance billing if they accept Medicare assignment.
She has called Medicare twice and gotten two different answers, hence her calling me (her son is a client).
Do I understand this correctly?
Let's assume the GHP has a $1500 deductible on a certain (outpatient) procedure then pays 80%. First bill of any kind for any doctor in 2017.
On a procedure, the negotiated rate with the GHP is $3000. Medicare's is $1500. Provider accepts GHP and Medicare assignment.
She has a $1500 deductible, then 20% coinsurance, so her GHP will pay $1200 and say she owes $1800.
Medicare's is supposed to pay 80% after part B deductible. They would not pay any, because the GHP had already paid the $1200, which is more than what they would normally be obligated to pay, in this case about $1055.
Lady additionally owes $182 part B deductible to doctor's office, plus the coinsurance of $108 to get the doctor paid $1500 total. Is that right?
Does the doctor's office have to take the $1200 from GHP + $300 from lady as paid in full because they accept Medicare assignment, or could they balance bill the woman for the rest of the $3000 her GHP has contracted? I know that I should know the answer to this, but it doesn't come up often because most people I have dealt with are already planning to terminate GHP before I get to them.
U65 just got her disability awarded and has been enrolled in Medicare A&B. She is still within the window to decline B. She is currently covered under her husband's active employment GHP. His employer is a large-group (over 100 employees), so from what I can tell GHP would be primary if she keeps both.
She wanted to know how Medicare would pay if she stayed on the B rather than declining it. Assume that the GHP coordinates benefits.
What I am not 100% clear on is outpatient and doctors balance billing if they accept Medicare assignment.
She has called Medicare twice and gotten two different answers, hence her calling me (her son is a client).
Do I understand this correctly?
Let's assume the GHP has a $1500 deductible on a certain (outpatient) procedure then pays 80%. First bill of any kind for any doctor in 2017.
On a procedure, the negotiated rate with the GHP is $3000. Medicare's is $1500. Provider accepts GHP and Medicare assignment.
She has a $1500 deductible, then 20% coinsurance, so her GHP will pay $1200 and say she owes $1800.
Medicare's is supposed to pay 80% after part B deductible. They would not pay any, because the GHP had already paid the $1200, which is more than what they would normally be obligated to pay, in this case about $1055.
Lady additionally owes $182 part B deductible to doctor's office, plus the coinsurance of $108 to get the doctor paid $1500 total. Is that right?
Does the doctor's office have to take the $1200 from GHP + $300 from lady as paid in full because they accept Medicare assignment, or could they balance bill the woman for the rest of the $3000 her GHP has contracted? I know that I should know the answer to this, but it doesn't come up often because most people I have dealt with are already planning to terminate GHP before I get to them.